Healthcare Provider Details

I. General information

NPI: 1104184456
Provider Name (Legal Business Name): LARRY ORDONEZ D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2012
Last Update Date: 04/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6310 BERGENLINE AVE
WEST NEW YORK NJ
07093-1620
US

IV. Provider business mailing address

6310 BERGENLINE AVE
WEST NEW YORK NJ
07093-1620
US

V. Phone/Fax

Practice location:
  • Phone: 201-869-6220
  • Fax: 201-869-5145
Mailing address:
  • Phone: 201-869-6220
  • Fax: 201-869-5145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License Number38MC00697700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: